Is the COVID pandemic presenting us with a new opportunity in the field to offer psychedelic-assisted psychotherapy online? Can we collaborate with patients to offer virtual sessions safely and effectively? If so, what are the implications of this new way of providing treatment? Join Dr. Eric Sienknecht, PsyD and Veronika Gold, LMFT in an exploration of offering ketamine-assisted psychotherapy online during social distancing.
Covid’s Effect on Mental Health
In mid-March 2020, the Shelter-In-Place order was put into effect in San Francisco. Nearly all businesses and services ground to a halt. We stayed home. Canceled all plans and appointments. We foraged for the meager supplies remaining in stores, and waited.
Our ketamine-assisted psychotherapy clinic, Polaris Insight Center closed for business indefinitely although we have continued to offer ketamine assisted psychotherapy training online. As fears of infection spread, along with the virus, we worried about our many patients. Some of our patients were suffering from treatment-resistant depression and anxiety. Meanwhile, others reported newly emergent symptoms, exacerbated by the stress of the pandemic.
The question on hand became: How could we best respond to this potential healthcare crisis?
Ketamine-Assisted Psychotherapy and Telemedicine
Telemedicine and HIPAA regulations were relaxed. After several meetings, we decided to begin offering virtual ketamine-assisted psychotherapy (KAP) sessions. Usually our physicians regularly provide suitable patients with prescriptions for ketamine lozenges for at-home use during maintenance phases of treatments. Furthermore, we typically require in-office medical and psychological evaluations as well as several in-office KAP sessions before transitioning to at-home regimens.
In this new COVID era, we would now conduct evaluations, determine treatment plans, and facilitate the self-administration of ketamine lozenges at home via Zoom. Moreover, this was all done without ever meeting the patient in person.
Readers with an understanding of the powerful, often transformative, effects of psychedelic medicine may be skeptical. One may wonder, “How is this possible?” Above all, “Is this safe?”
We also had similar questions, which informed the development of a new protocol for virtual services that included additional requirements to maximize safety and support.
Consider these three dimensions of virtual ketamine-assisted psychotherapy.
1. Accessibility of Ketamine-assisted Psychotherapy Online
Upsides
Virtual KAP is more affordable compared to in-office treatment. Standard KAP treatment is a significant time investment. At minimum, typical treatments include:
- 1/2 hour with the physician
- 1-hour intake with the therapist
- 1-3 hours of preparation
- Several 2 to 3 hour experiential sessions
- Finally, 1 or more 1-hour integration therapy sessions
Because off-label use of ketamine is not usually reimbursed by insurance companies, the 10-20 hours or more of treatment are typically paid out of pocket. Virtual sessions allow for clinic rent savings. Additionally, there is less time spent between sessions. Consider time in the waiting room, transition time between session and transportation, time changing sheets, and time resetting the room. As a result, virtual sessions allow clinicians to see more patients.
In comparison to an in-person clinic visit, virtual KAP is more accessible. People live in remote areas and places where there are no ketamine-assisted psychotherapy clinics. Now they have access to this treatment.
KAP is most often used to target treatment-resistant depression. One of the common challenges with depression for people is finding the motivation to engage in treatment. Think: planning for sessions, leaving the house, driving to and from appointments, etc. Virtual sessions remove these roadblocks. Meanwhile, they facilitate access to, and engagement in, treatment delivery.
Home Setting Benefits
The home setting can be more convenient for supporting the inner process and reducing side effects. Patients can stay with their process without interruption beyond the time of the session. Ketamine can elicit non-ordinary states of consciousness. Even when patients return to their normal state of consciousness, the physical effects of the medicine can continue beyond the time of the session.
For this reason, many clinics, like ours, have “recovery areas.” Patients wait here to stabilize. Additionally, patients wait here for their required, arranged ride home. Alternatively, with home treatment, the patient can stay in their bed or on their sofa for as long as they need. There is no pressing need to shift the state and commute home. Moreover, one of the most common side effects of ketamine therapy is nausea. Nausea is exacerbated by movement. So home sessions greatly decrease this, as the patient can stay in a comfortable position as long desired.
Downsides
Due to online format limitations, there is a greater need to communicate instructions clearly. During in-office sessions, the therapist/physician team are responsible for creating the setting and co-creating the set of the sessions. During online sessions, the patient has to prepare the set and setting themselves.
As such, additional communication around preparation details are needed. Think: from interacting with the compounding pharmacy, to learning how to use the lozenges, to setting up the music, to navigating online platforms. Instructions need explicit spelling out and frequent repetition. In short, the provider requires more energy and effort on the front end to facilitate a smooth, safe, and supportive experience.
2. Safety of Ketamine-assisted Psychotherapy Online
Upsides
Virtual sessions in a familiar home setting are experienced as safer for some patients. This allows for the possibility of greater vulnerability and increased capacity to fully let go into the therapeutic process. As human beings, we are wired for relationships. In healthy individuals, personal contact and connection facilitates relaxation, feelings of joy, and openness. However, for many people who suffer with depression, anxiety, and PTSD, personal contact and/or being in clinical settings can increase their discomfort. Thus, a clinical setting can create an obstacle to depth exploration.
Downsides
Patient safety and legal concerns for our clinic required us to spend more time and energy upfront anticipating risks and creating contingency plans. We developed new informed consents. These include a telehealth consent and an at-home lozenge-use consent. These describe in detail set and setting requirements, safety plans, and the importance of support systems. Additionally, since we would be expanding our services to people outside the Bay Area, we created new contact lists for local emergency services for various areas in California.
3. Support System for Ketamine-assisted Psychotherapy Online
Upsides
Particularly since the onset of the pandemic, there has been a greater need for connection with others and as well with those who are familiar with KAP. We find ourselves sharing more community online resources with our patients and discussing the importance of ketamine integration groups. We see much more interest in virtual support groups. For example, consider the weekly Psychedelic Integration Circles with Tam Integration and Polaris Insight Center as well as the weekly Ketamine Integration Circles with Sage Integrative Health.
Downsides
The patient’s support system is even more important if they are engaging in virtual sessions. Communicating with the patient’s support system needs time and energy. In cases involving extreme social isolation, inability to communicate with others, and/or absence of a support system could be a major obstacle to this kind of treatment.
In comparison to in-person sessions with a physically present therapist/physician providing verbal and physical support, patients can sometimes find it harder to take in the support during a virtual session. Thus, having a sitter present during the session should be arranged. The sitter can be in the same room or a separate one. At least have someone who is aware that the patient is taking a journey and can be on-call if necessary.
Favorable Outcomes
Witnessing the favorable outcomes of this new collaboration method between providers and patients reveals broader implications for our healthcare system. Patients receiving home treatment might be less dependent on the system for their healthcare needs. As a result, this leads to greater self-empowerment and agency, meaning less strain on the healthcare system. Furthermore, with at-home sessions being significantly less expensive than in-office treatments, access to care widens.
With at-home sessions being provided by more clinics, the importance of ongoing safety and efficacy tracking needs to be revised accordingly, as well as protocols. Nevertheless, after successfully facilitating many at-home treatments, it is our belief that virtual KAP sessions can be provided safely and effectively when paired with sufficient screening, preparation, and support.
